Healthcare Provider Details

I. General information

NPI: 1932257193
Provider Name (Legal Business Name): SAN DIEGO PRIMARY CARE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2007
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 MORAGA AVE STE B408
SAN DIEGO CA
92117-5364
US

IV. Provider business mailing address

3737 MORAGA AVE STE B408
SAN DIEGO CA
92117-5364
US

V. Phone/Fax

Practice location:
  • Phone: 858-292-8885
  • Fax: 858-292-0688
Mailing address:
  • Phone: 858-292-8885
  • Fax: 858-292-0688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberG31968
License Number StateCA

VIII. Authorized Official

Name: GARY KENNETH BOONE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 858-292-8885